What is the recommended treatment and testing for a pediatric patient with a 1-week history of diarrhea?

Management of Pediatric Diarrhea Lasting One Week

For a pediatric patient with a one-week history of diarrhea, oral rehydration therapy should be the primary treatment, with laboratory assessment and stool testing indicated if symptoms are moderate to severe or if there are signs of dehydration. 1

Assessment of Dehydration

The severity of dehydration should be assessed using a combination of clinical signs:

• Key physical examination findings 2:

  • Prolonged capillary refill time (>2 seconds)
  • Abnormal skin turgor (skin pinch retracts slowly)
  • Abnormal respiratory pattern
  • Dry mucous membranes
  • Sunken eyes or fontanelle
  • Decreased urine output
  • Lethargy or altered mental status

• Severity classification 1:

  • Mild to moderate: <4 stools/day with minimal systemic symptoms
  • Severe: ≥4 stools/day, fever >38.5°C, abdominal pain, or leukocytosis

Laboratory Testing

Testing should be guided by symptom severity:

• For mild cases with no signs of dehydration:

  • Laboratory testing generally not required 1

• For moderate to severe cases or signs of dehydration:

  • Serum electrolytes (sodium, potassium)
  • Acid-base status
  • Renal function (urea, creatinine) 1
  • Stool testing for C. difficile toxin if symptoms are moderate to severe 1

Treatment Approach

1. Rehydration (Primary Focus)

• Oral Rehydration Therapy (ORT) for mild to moderate dehydration:

  • Use reduced osmolarity ORS containing 65-70 mEq/L sodium and 75-90 mmol/L glucose 1
  • Preparation: 3.5g NaCl, 2.5g NaHCO₃, 1.5g KCl, and 20g glucose per liter of clean water 1
  • Target volume: At least 20-25 mL/kg of ORS during initial rehydration phase 3
  • Children who can tolerate approximately 25 mL/kg of ORS are more likely to be successfully managed at home 3

• Intravenous Fluids indicated for:

  • Severe dehydration
  • Shock
  • Altered mental status
  • Failure of ORT 1, 4
  • Use isotonic fluids such as lactated Ringer's or normal saline 1

2. Nutrition

• Continue breastfeeding throughout the diarrheal episode (strong recommendation) 1
• Resume age-appropriate diet during or immediately after rehydration 1, 5
• Avoid spicy foods, foods high in simple sugars and fats 1

3. Medications

• Antimicrobial therapy:

  • Only if bacterial infection is strongly suspected or confirmed 1, 6
  • Tailor antibiotics based on microbial isolation when available 1

• Contraindicated medications in children:

  • Antimotility drugs (e.g., loperamide) are contraindicated in children under 18 years with acute diarrhea 1
  • Antiemetics (except ondansetron in children over 4 years) 1
  • Antidiarrheals and spasmolytics are unnecessary and potentially risky 6

• Adjunctive therapies:

  • Probiotics may be offered to reduce symptom severity and duration (weak recommendation) 1
  • Zinc supplementation for children 6 months to 5 years with signs of malnutrition 1

Monitoring and Follow-up

• Reassess after 48-72 hours of treatment 1
• Consider alternative diagnoses or treatment failure if no improvement 1

Indications for Hospitalization

• Severe dehydration (>9% of body weight)
• Shock or hemodynamic instability
• Altered mental status
• Persistent vomiting preventing ORT
• Failure to improve with outpatient management
• Social concerns about adequate home care 1

Warning Signs Requiring Immediate Attention

• Severe abdominal pain or distension
• Persistent high fever
• Blood in stools
• Signs of severe dehydration or shock
• Toxic appearance 1

Common Pitfalls to Avoid

• Overuse of antibiotics for likely viral gastroenteritis 6
• Premature use of IV fluids without adequate trial of ORT 3
• Unnecessary dietary restrictions that may worsen nutritional status 1, 5
• Use of antidiarrheal medications in children 1, 6
• Failure to recognize persistent diarrhea (>14 days) which may indicate a different etiology requiring specific investigation 5